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In recent years it has become customary to publish the design of a clinical trial at the time that the trial commences. When the results of the trials become available for publication at a later time point, the methods can be described briefly, while referring to the previously published design paper. In this issue of the journal, Tra et al. [1] publish the design of a retrospective study (not a clinical trial) evaluating adherence to guideline-recommended management in patients with acute coronary syndromes (ACS) in 13 Dutch hospitals in 2012. An expert panel identified three recommendations: timely invasive management in ST-segment elevation myocardial infarction (STEMI) patients, use of a validated risk score in non-STEMI/unstable angina (NSTEMI/UA) patients and prescription of secondary prevention medication (the golden five) at discharge in ACS patients. Hospital chart review, abstracting of patient records and data from hospital information systems will be collected by trained data abstracters. The primary endpoint will be the percentage of patients achieving reperfusion within 90 min from first medical contact, percentage of patients in whom a validated risk score was used and percentage of patients discharged on acetylsalicylic acid, thienopyridine, statin, beta blocker, and ACE inhibitor. Importantly , contraindications for prescription of medication will be recorded. The use of a retrospective, cross-sectional design to evaluate the quality and performance of hospitals in the management of patients with ACS has several important shortcomings. The retrospective nature of the data collection will result in many missing items. The information in the patients charts is recorded for clinical purposes, not for performance measures , and will therefore be subject to all kinds of bias and confounding. ACS patients are a particular heterogeneous population that may have a very dynamic pre-hospital, in-hospital and post-discharge clinical course which is difficult to reconstruct retrospectively. This is difficult for cardiologists with years of clinical experience, as evident from discussions in clinical endpoint committees in ACS trials, and this may even be more difficult for data abstracters trained in social sciences. Prospective collection of performance measures has been performed previously in large studies, but this provides only a distant reflection of quality of patient care. It is extremely difficult to measure quality of care even in a prospective design, so one is left with what we can measure, such as time between first medical contact to balloon within 90 min yes/no, use of risk score yes/no or prescription of …

Measuring hospital performance in the management of acute coronary syndromes